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- t <br /> NON-HAZARDOUS 1.Generator ID Number 2 Page 1 of I Emergency Response Phone 4.Waste Tracking Number <br /> WASTE MANIFEST R-1! AF PUCABLE 2 <br /> 5.Generators Name and Mailing Address GerteraWs Site Address(it different than maitg address) <br /> G `��t�Phone: Qct. 4 0�'� ►, cA 95Z.15 ,I*kA , CA <br /> Anem6.Transporter 1 Company NameU.S.EPA ID Number <br /> GYM _r,,r,, i4 NOT APPUCABLE <br /> 7.Transporter 2 Company Name I ` U.S EPA ID Number <br /> i <br /> NOT APPLICABLE � <br /> 8.Designated Facility Name and Site Address U.S.EPA ID Number <br /> RECOLOGY 14AY ROAD MAR 0 3 2015 NOT APPLICABLE <br /> HAY ROAD-VACAVILLE, CA 9W7 <br /> Facil 's Phone: f 1 � a4 <br /> 9.Waste Shipping Name and Desedplba 'N}= r T`f r1±rgR, 1b rs 11.Total 12 Unit <br /> No. Type Ouantiry WUVol. <br /> 1. <br /> 2 <br /> oC <br /> W <br /> Z 2. <br /> W <br /> 3 - <br /> i <br /> 4 <br /> 13.Special Handrrng Instructions and Additional Intorm31ion <br /> 14.GENERATOR'S/OFFEROR'S CERTIFICATION:I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, <br /> marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable international and national governmental regulations. <br /> GeneratoesfONerors Printeci Typed1 Name Signature Month Day Year <br /> J 15.International Sftipments II� <br /> ❑Import 10 U.S. u Export from U.S. 1�or1 of entry/eft <br /> Transporter Signature for exports ): Date leavin U.S.: <br /> I <br /> 16.Transporter Acknowledgment of Receipt of Materials <br /> ETransporter 1 Printeci Typed Name Signature J Month Day Year <br /> IL J1 Sc <br /> aTransporler2 Prnted/Typed Name Signature Month Day Year <br /> 17.Discrepancy <br /> 17a.Discrepancy Indication Space <br /> ❑Quantity �Type ❑Residue ❑Partial Rejection Full Rejection <br /> i <br /> Manifest Reference Number. <br /> 17b.Allemate Facility(or Generator) U.S.EPA ID Number <br /> J I <br /> U <br /> a Facitity's Phone: <br /> W 17c.Signature of Alternate Facility(or Generator) Month Day Year I <br /> a <br /> z <br /> (7 <br /> W <br /> 18.Designated Facility Owner or Operator.Certification of receipt of materials covered by the manifest except as noted in Item 17a <br /> Printed(Typed Name Signature. Month Day Year <br /> 5 <br /> 169-BLS-C 5 11979(ReV69)9/99) DESIGNATED FACILITY'S COPY <br />